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Use and Disclosure of Health Information for Treatment, Payment, or Healthcare Operations

I understand that as part of my healthcare practitioner and their affiliated partners originate and maintain health records describing my health history, symptoms, examination and test results, diagnoses, treatment and any plans for future care or treatment. I understand that this information is utilized to plan my care and treatment, to bill for services provided to me, to communicate with other healthcare providers and other routine healthcare operations such as assessing quality and reviewing competence of healthcare professionals.
Notice of Privacy Practices provides specific information and complete description of how my personal health information may be used and disclosed. I have been provided a copy of or access to the Notice Privacy Practices of and understand that I have the right to review the notice prior to signing this consent. I understand that my healthcare practitioners and their affiliated partners reserve the right to change the Notice of Privacy Practices will be mailed to me if I provide my address below. I understand that I have the right to restrict the use and/or disclosure of my personal health information for treatment, payment or healthcare operations and that my healthcare practitioners and their affiliated partners is not required to agree to the restrictions requested. It may revoke this consent at any time in writing except to the extent of my healthcare practitioner and their affiliated partners have already taken action in reliance on my prior consent. This consent is valid until revoked by me in writing.

I further understand that any and all records, whether written, oral or in electronic format, are confidential and cannot be disclosed without my prior written authorization, except as otherwise provided by law.

AUTHORIZATION AND IRREVOCABLE INSTRUCTIONS TO HEALTHCARE PRACTITIONER FOR MEDICARE, MEDICAID AND ALL OTHER INSURANCE PLANS

"I hereby authorize and irrevocably instruct any physician, health care practitioner, hospital, clinic, or other medical or medically related facility to furnish any and all records, medical history, services rendered or treatment given to me or any dependent for purposes of review, investigation or evaluation of any claim submitted to Health Insurance Plans.

I also authorize Medicare, Medicaid or/and other Health Insurer to disclose to a hospital or health care service plan, self-insurer, or an insurer any medical information obtained if such disclosure is necessary to allow the processing of any claim.

If my coverage is under a Group Contract held by an employer, an association, trust fund, union or similar entity, this authorization also permits disclosure to them for purposes of utilization review or audit. This authorization shall become effective immediately upon execution and snail remain in effect for the duration of any claim or term of coverage with BLUE SHIELD or other insurer including a reasonable time thereafter, until its final consummation.

This authorization shall be binding upon me, my dependents, and our heirs, executors and administrators."

MEDICARE AND MEDICAID

"I request that payment of authorized Medicare benefits be made my behalf to this office for any services furnished by that physician to me. I authorize any holder of medical information about me to release to the Health Care Financing Administration and its agents any information needed to determine these benefits or the benefits payable for related services."

AUTHORIZATION AND IRREVOCABLE INSTRUCTION TO PAY FOR SERVICES RENDERED:

"I request payment of this claim and, if the payer accepts assignment, authorize payment direct to the physician group, physician, health care practitioner, hospital, clinic, or supplier for the services described."

I Authorize Amerihealth Group on behalf of physician group, physician, health care practitioner, hospital, clinic, or supplier to bill my health insurance account for the health services provided to me. In the event that the Company is unable to obtain from my insurance provider payments for the services, I authorize the Company to charge my credit or debit card for agreed upon purchases of the services.

I understand that my information will be saved to a file for future transactions on my account. I understand that the Company reserves any and all rights applicable under the law to collect my outstanding debt, including but not limited to employing services of third-party
collectors.

I give consent to the Company to contact me via e-mail, phone, or text messages for administrative, Healthcare, billing, and other purposes in connection to the services provided by the Company. It is my understanding I may be contacted via an automated dialer or messaging system and pre-recorded messages will be left from the automated system if I am unable to accept the call.